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healh assemsnt instructions

pls see attachemnt for further insturcitons 

Case 3

Chief Complaint
(CC) 

“I have been having frequents headaches lately”

History of Present Illness (HPI)

A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile.

PMH

Frequent headaches since I was 15, with menses.

Drug Hx

Ibuprofen for Headaches

Subjective

Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day

 VS

B/P 108/64; Pulse 86; RR 16; Temp 98.6;

 General

25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room

 HEENT

no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision

Lungs

CTA AP&L

Card

S1S2 without rub or gallop

Abd

benign, normoactive bowel sounds x 4;

Rectal exam

Non contributory

Integument

intact without lesions masses or rashes.

Neuro

Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL

Once you received your case number, answer the following questions:

1.
What other subjective data would you obtain?

2.
What other objective findings would you look for?

3.
What diagnostic exams do you want to order?

4.
Name 3 differential diagnoses based on this patient presenting symptoms?

5.
Give rationales for your each differential diagnosis.

6.
What teachings will you provide?

 

Submission Instructions:

·
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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